American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016

The use of endoluminal techniques in the revision of primary bariatric surgery procedures: a systematic review

Background

Weight regain following primary bariatric surgery is attributed to anatomical, behavioural and hormonal factors. Dilation of the gastrojejunal anastomosis is a possible cause of weight regain after roux-en-Y gastric bypass (RYGB). However, surgical revision has significant risks with limited benefits. Endoluminal procedures have been suggested to manage weight regain post-surgery. This systematic review aims to assess efficacy of endoluminal procedures.

Methods

Studies where endoluminal procedures were performed following primary bariatric surgery were identified. Main outcome measures were mean weight loss pre- and post-procedure, excess weight loss, recurrence rates, success rates and post-procedure complications.

Results

Twenty-six studies were included in this review. Procedures identified were (i) endoluminal plication devices (ii) other techniques e.g. sclerotherapy, mucosal ablation, and Argon Plasma Coagulation (APC) and (iii) combination therapy involving sclerotherapy/mucosal ablation/APC and endoscopic OverStitch device. Endoluminal plication devices show greatest initial weight loss within 12 months post-procedure, but not sustained at 18 months. Only one study utilising sclerotherapy showed greater sustained weight loss with peak EWL (19.9%) at 18 months follow-up. Combination therapy showed the greatest sustained EWL (36.4%) at 18 months. Endoluminal plication devices were more successfully performed in 91.8% of patients and had lower recurrence rates (5.02%) compared to sclerotherapy and APC, with 46.8% success and 21.5% recurrence rates. Both procedures demonstrate no major complications and low rates of moderate complications. Only mild complications were noted for combination therapy.

Conclusions

The paucity of good quality data limits our ability to demonstrate and support the long-term efficacy of endoluminal techniques in the management of weight regain following primary bariatric surgery. Future work is necessary to not only clarify the role of endoluminal plication devices, but also combination therapy in the management of weight regain following primary bariatric surgery.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07468-w) contains supplementary material, which is available to authorized users.

Impact of bariatric surgery on cancer risk reduction

Obesity is second only to tobacco as a preventable cause of cancer in the US. By multifactorial and often additive mechanisms, obesity leads to the development and promotion of 40% of the cancers diagnosed in this country, including post-menopausal breast, endometrial, colorectal, kidney, liver and pancreatic cancers, among others. Though prevention of obesity should be the ultimate goal of thoughtful and effective healthcare practices, it remains a highly prevalent condition, and morbid obesity (BMI ≥40 Kg/m²) can be refractory to lifestyle interventions in many cases. Currently bariatric surgery is an effective treatment strategy for individuals who suffer from morbid obesity or obesity with associated co-morbidities and fail to lose weight under a medically supervised diet and exercise program. The current review addresses seminal studies that have investigated the potential cancer prevention effects of bariatric surgery, demonstrating a positive impact mostly in post-menopausal breast and endometrial cancers. The controversial association between bariatric surgery and increased colorectal cancer (CRC) risk is also recognized and discussed. Finally, while bariatric surgery should not be routinely recommended as a cancer prevention strategy, it has the potential to decrease the risk for certain types of cancers as a collateral beneficial effect.

How many sleeve gastrectomies are done at nonaccredited centers in Texas?

BACKGROUND

The American College of Surgeons created the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to improve the safety of surgery and track outcomes of patients undergoing metabolic and bariatric surgery. The MBSAQIP captures all surgical procedures performed at accredited centers (AC) but not all metabolic and bariatric surgery cases performed in the United States. Texas has a large statewide administrative database that tracks nearly all surgical procedures performed in the state and we proposed using this database to assess the number of sleeve gastrectomies (SG) and whether they were performed at an AC or not.

OBJECTIVE

Our objective was to determine the percentage of SG that are performed in MBSAQIP ACs.

SETTING

University surgical department, United States.

METHODS

The Texas Inpatient and Outpatient Public Use Data Files (PUDF) for the year 2017 were examined. We used the Current Procedural Terminology and International Classification of Diseases version 10 codes for SG, 43775 and 0 DB64 Z3, respectively. We compared the PUDF facility list to a list of MBSAQIP ACs in Texas.

RESULTS

There were 4549 SG performed in Texas in 2017 reported in the Outpatient PUDF. Of these, 80.8% of cases were performed at ACs. Of the 136 facilities in the outpatient PUDF performing SG, 58 were MBSAQIP accredited. In the Inpatient PUDF for 2017 there were 11,287 SG, of which 9829 (87%) were performed at ACs. Of 153 centers performing SG, 77 were MBSAQIP accredited. There was a higher percentage of adjustable band conversions to SG at non-ACs in the Outpatient PUDF than the Inpatient PUDF.

CONCLUSION

The MBSAQIP database is missing almost 20% of outpatient SG performed in Texas and 13% of inpatient SG. Administrative databases can be used to externally validate the MBSAQIP.

Changes in center of pressure velocities during obstacle crossing one year after bariatric surgery

Adults with obesity have atypical gait with poor balance leading to an increase in fall risk. After massive weight loss, their gait improves. However, we know little about changes in postural stability after massive weight loss. The present study aimed to examine how massive weight loss after Roux-en-Y bariatric surgery affected adjustments in center of pressure (COP) velocities during flat ground walking and obstacle crossing. Before and one-year post-bariatric surgery, nineteen female adults walked under four conditions: baseline walking on flat ground and obstacle crossing with three different obstacle heights for a total of 20 trials. COP data were obtained from raw pressure time series data extracted from a gait carpet. Massive weight loss increased anteroposterior COP velocities under the midfoot of both trailing and leading legs (ps<.01) and decreased mediolateral COP velocities under the forefoot of trailing leg (p < .05). Decreased BMI from pre- to post-surgery was correlated with an increase in anterior-posterior and decrease in medial-lateral COP velocities and with increased velocity (ps<.05). Massive weight loss not only improved gait but also facilitated effective balance control strategies. Examining how massive weight loss affects adjustments in COP velocity may help create ways to better understand why individuals with obesity have atypical gait with poor balance and how we can facilitate participation in physical activities.

Safety and efficacy of endoscopic sleeve gastroplasty worldwide for treatment of obesity: a systematic review and meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) has gained momentum as a promising, minimally invasive bariatric therapy worldwide.

OBJECTIVE

We performed the first comprehensive systematic review and meta-analysis of studies to evaluate the efficacy, safety, and procedural technique of ESG.

METHODS

Bibliographic databases were systematically searched for studies assessing patients who underwent ESG for the treatment of obesity. Studies were included if they reported percent total weight loss or percent excess weight loss and the incidence of serious adverse events. Studies with <15 patients, follow-up period <6 months, and overlapping patients were excluded.

RESULTS

Eight observational studies with 1859 patients were included. Pooled mean percent total weight loss at 6, 12, and 24 months was 14.86 (95% confidence interval [CI]: 13.83-15.90), 16.43 (95%CI: 15.23-17.63), and 20.01 (95%CI:  16.92-23.11), respectively. Pooled mean percent excess weight loss at 6, 12, and 24 months was 55.75 (95%CI: 50.61-60.89), 61.84 (95%CI: 54.75-68.93), and 60.40 (95%CI: 48.88-71.92), respectively. The pooled incidence of serious adverse events was 2.26% (95%CI 1.25-4.03) and no mortality was reported. Gastrointestinal bleeding and perigastric fluid collection were the most common reported serious adverse events; however, the pooled incidence of both was <1%. Variations in procedural technique were seen, but the full-thickness nature of suturing was reported in all studies. A layer of reinforcement sutures was performed in the majority of studies (n = 6). Limitations include the lack of controlled studies, long-term follow-up data, and standardization of technique.

CONCLUSION

ESG, a minimally invasive bariatric therapy, is reproducible among centers worldwide with effective weight loss and favorable safety profile outcomes. Controlled studies would be valuable to further corroborate these findings.

Obesity-related hypertension: a review of pathophysiology, management, and the role of metabolic surgery

Obesity is a significant public health challenge worldwide and is inextricably linked to adverse cardiovascular outcomes. The relationship between excess adiposity and increased blood pressure is well established, and it is estimated that obesity accounts for 65-78% of cases of primary hypertension. The mechanisms through which obesity causes hypertension are complex and include sympathetic nervous system overactivation, stimulation of the renin-angiotensin-aldosterone system, alterations in adipose-derived cytokines, insulin resistance, and structural and functional renal changes. Weight loss is the primary goal of treatment for obesity-related hypertension, although few individuals achieve success with nonpharmacological management alone. Specific considerations apply when selecting the most appropriate pharmacological therapy for obese hypertensive patients. Metabolic surgery has proved to be the most effective means of ensuring substantial and sustained weight loss and has also been shown to confer beneficial effects in type 2 diabetes mellitus. Increasing evidence suggests that metabolic surgery may also be an effective treatment for obesity-related hypertension, although prospective data on long-term blood pressure outcomes are awaited. This review will discuss the pathophysiological mechanisms that link obesity with hypertension and will provide an overview of treatment strategies, with a focus on metabolic surgery.

Impact of sleeve gastrectomy and dietary change on metabolic and hepatic function in an obesity rat model - Experimental research

PURPOSE

Sleeve gastrectomy (SG) is an effective procedure to treat morbid obesity. SG induces remission of type 2 diabetes and metabolic syndrome and improves non-alcoholic fatty liver disease (NAFLD). However, it is imperative to clarify the extent to which these beneficial effects may be attributed to SG among other concomitant changes including postoperative diet. The current study addresses this question in a rodent model of obesity by subjecting it to SG, normal diet, or a combination of the two.

METHODS

Male Wistar-rats were fed with either high fat diet (HF, n = 32) or received chow diet (CD, n = 8). After 15 weeks, the HF-fed rats underwent either SG or sham operation, following which they were randomised to either continue HF or switched to CD for another 6 weeks. Body weight, fasting blood glucose level, blood pressure, and adipokine expression (leptin, adiponectin, MCP-1) in the adipose tissue along with triglycerides level in the blood serum were assessed to evaluate metabolic function. Hepatic function was assessed by histological evaluation of liver fibrosis (Hydroxyproline, Sirius Red) and reverse transcription polymerase chain reaction (RT-PCR) of the inflammation marker monocyte chemoattractant protein-1 (MCP-1).

RESULTS

Postoperative dietary change improved adipose tissue inflammation and arterial blood pressure regardless of the surgical intervention, while SG improved hyperglycaemia, blood triglyceride levels and, regardless of the postoperative diet, hepatic inflammation and fibrosis. However, combined administration of SG with post-operative normal diet was the most effective with regard to reducing the body weight.

CONCLUSION

HF for 15 weeks induced obesity with metabolic syndrome and NAFLD in rats. SG and dietary intervention improved metabolic state and NAFLD; however, their combination was significantly more effective.

The incidence of orthostatic intolerance after bariatric surgery

AIMS

Every year, over 200 000 individuals undergo bariatric surgery for the treatment of extreme obesity in the United States. Several retrospective studies describe the occurrence of orthostatic intolerance (OI) syndrome after bariatric surgery. However, the incidence of this syndrome remains unknown.

MATERIALS AND METHODS

We used a prospective, de-identified registry of 4547 patients who have undergone bariatric surgery at Vanderbilt to identify cases of new-onset OI. Structured chart reviews were conducted for all subjects who reported new-onset OI post surgery. Cases of OI were confirmed using an operational case definition developed by the Vanderbilt Autonomic Dysfunction Center, and autonomic function tests results were examined for evidence of impaired autonomic function. The cumulative incidence of post-bariatric surgery OI syndrome was estimated using a life table.

RESULTS

Seven hundred forty-one of 4547 (16.3%) patients included in our cohort reported new OI symptoms after surgery. After the chart review, we confirmed the presence of post-bariatric surgery OI syndrome in 85 patients, 14 with severe OI requiring pressor agents. At 5 years post surgery, follow-up is reduced to 15%; the unadjusted 5-year prevalence of OI was 1.9%. The cumulative incidence of OI syndrome adjusted for loss of follow-up was 4.2%. Most OI cases developed during weight-stable months (±5 kg). At the time of identification, 13% of OI cases showed evidence of impaired sympathetic vasoconstrictor activity.

CONCLUSION

OI is frequent in the bariatric population, affecting 4.2% of patients within the first 5 years postoperatively. In 13% of post-bariatric surgery OI patients, there was evidence of impaired sympathetic vasoconstriction activity.

Surgical strategy for gastroesophageal reflux disease in patients with obesity

Gastroesophageal reflux disease (GERD) and obesity have become serious problems affecting global health. The surgical treatment strategy for GERD patients with obesity is still a difficult point. In particular, obesity exacerbates the occurrence of GERD, and simple anti-reflux surgery has limited efficacy in obese patients. Currently, bariatric surgery is a good choice for the treatment of such patients, and Roux-en-Y gastric bypass is the best choice. Revisional surgery remains to be standardized for serious complications in postoperative patients. In addition, the new anti-reflux bariatric surgery that has been emerging in recent years is expected to be an effective alternative treatment for GERD patients with obesity.

Bariatric Surgery as a Long-Term Treatment for Type 2 Diabetes/Metabolic Syndrome

Metabolic surgery is increasingly becoming recognized as a more effective treatment for patients with type 2 diabetes (T2D) and obesity as compared to lifestyle modification and medical management alone. Both observational studies and clinical trials have shown metabolic surgery to result in sustained weight loss (20–30%), T2D remission rates ranging from 23% to 60%, and improvement in cardiovascular risk factors such as hypertension and dyslipidemia. Metabolic surgery is cost-effective and relatively safe, with perioperative risks and mortality comparable to low-risk procedures such as cholecystectomy, hysterectomy, and appendectomy. International diabetes and medical organizations have endorsed metabolic surgery as a standard treatment for T2D with obesity.

Association of the addition of a transversus abdominis plane block to an enhanced recovery program with opioid consumption, postoperative antiemetic use, and discharge time in patients undergoing laparoscopic bariatric surgery: a retrospective study

Background

Increasing numbers of laparoscopic bariatric surgeries are being performed and enhanced recovery from anesthesia and surgery (ERAS) protocols have been implemented to optimize care for these patients. We evaluated the effects of an anesthesiologist placed preoperative transversus abdominis plane block (TAP) as part of a bariatric surgery ERAS protocol. We hypothesized that an anesthesiologist placed preoperative TAP added to an ERAS protocol following laparoscopic bariatric surgery would reduce total opioid consumption.

Methods

A retrospective cohort of consecutive patients between January 1, 2017 and December 31, 2018 at a single large tertiary care center studied. TAP blocks were added to the ERAS protocol beginning in the second quarter of 2017. The primary outcome was total opioid analgesia use in mg oral morphine equivalents. Secondary outcomes were antiemetics administered and length of hospitalization. Data were analyzed using a generalized linear mixed model adjusted for sociodemographic, surgical, and preoperative risk factors that have been associated with opioid and antiemetic use and length of hospitalization.

Results

Five hundred and nine cases were analyzed; TAP blocks were performed in 94/144 (65%) laparoscopic Roux-en-Y gastric bypass (LRYGB) and in 172/365 (47%) laparoscopic sleeve gastrectomy (LSG) patients. Mean (95% CI) adjusted total opioid administered was lower by 11% (1% to 19%, p=0.02), antiemetic drug administration was lower by 15% (-2% to 25%, p=0.06) and discharge time lower by 39% (26% to 48%, p<0.01) following LRYGB in the TAP group. Mean (95% CI) adjusted total opioid administered was lower by 9% (2% to 16%, p<0.01), antiemetic drug administration was lower by 11% (3% to 18%, p<0.01) and discharge time lower by 11% (2% to 18%, p=0.02) following LSG in the TAP group.

Conclusions

TAP blocks added to a laparoscopic bariatric surgery ERAS protocol were associated with decreased total opioid use, number of antiemetic treatments, and length of stay; however, these changes were not likely clinically important. Our findings do not support widespread clinical benefit of TAP use in ERAS protocols for laparoscopic bariatric surgery.

American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States

BACKGROUND

Metabolic and bariatric surgery, despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate therapy.

OBJECTIVES

The objective of this study was to provide the best estimated number of metabolic and bariatric procedure performed in the United States in 2018.

SETTING

United States.

METHODS

We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2018 were compared mainly with data from the previous 2 years.

RESULTS

Compared with 2017, the total number of metabolic and bariatric procedures performed in 2018 increased from approximately 228,000 to 252,000. The sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Finally, intragastric balloons placement continues as a significant contributor to the cumulative total number of procedures performed but declined from the previous year.

CONCLUSIONS

There was a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared with 2017, with an overall increase of approximately 60% since 2011. When taking into account primary procedures only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.

Effect of Surgical Versus Medical Therapy on Diabetic Kidney Disease Over 5 Years in Severely Obese Adolescents With Type 2 Diabetes

OBJECTIVE

To compare diabetic kidney disease (DKD) rates over 5 years of follow-up in two cohorts of severely obese adolescents with type 2 diabetes (T2D) undergoing medical or surgical treatment for T2D.

RESEARCH DESIGN AND METHODS

A secondary analysis was performed of data collected from obese participants of similar age and racial distribution enrolled in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and the Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) studies. Teen-LABS participants underwent metabolic bariatric surgery (MBS). TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy given for glycemic progression. Glycemic control, BMI, estimated glomerular filtration rate (eGFR), urinary albumin excretion (UAE), and prevalence of hyperfiltration (eGFR ≥135 mL/min/1.73 m²) and elevated UAE (≥30 mg/g) were assessed annually.

RESULTS

Participants with T2D from Teen-LABS (n = 30, mean ± SD age, 16.9 ± 1.3 years; 70% female; 60% white; BMI 54.4 ± 9.5 kg/m²) and TODAY (n = 63, age 15.3 ± 1.3 years; 56% female; 71% white; BMI 40.5 ± 4.9 kg/m²) were compared. During 5 years of follow-up, hyperfiltration decreased from 21% to 18% in Teen-LABS and increased from 7% to 48% in TODAY. Elevated UAE decreased from 27% to 5% in Teen-LABS and increased from 21% to 43% in TODAY. Adjusting for baseline age, sex, BMI, and HbA_1c, TODAY participants had a greater odds of hyperfiltration (odds ratio 15.7 [95% CI 2.6, 94.3]) and elevated UAE (27.3 [4.9, 149.9]) at 5 years of follow-up.

CONCLUSIONS

Compared with MBS, medical treatment of obese youth with T2D was associated with a higher odds of DKD over 5 years.

Bariatric surgery is a cost-saving treatment for obesity-A comprehensive meta-analysis and updated systematic review of health economic evaluations of bariatric surgery

Demand for bariatric surgery to treat severe and resistant obesity far outstrips supply. We aimed to comprehensively synthesise health economic evidence regarding bariatric surgery from 1995 to 2018 (PROSPERO registration number: CRD42018094189). Meta-analyses were conducted to calculate the annual cost changes "before" and "after" surgery, and cumulative cost differences between surgical and nonsurgical groups. An updated narrative review also summarized the full and partial health economic evaluations of surgery from September 2015. N = 101 studies were eligible for the qualitative analyses since 1995, with n = 24 studies after September 2015. Quality of reporting has increased, and the inclusion of complications/reoperations was predominantly contained in the full economic evaluations after September 2015. Technical improvements in surgery were also reflected across the studies. Sixty-one studies were eligible for the quantitative meta-analyses. Compared with no/conventional treatment, surgery was cost saving over a lifetime scenario. Additionally, consideration of indirect costs through sensitivity analyses increased cost savings. Medication cost savings were dominant in the before versus after meta-analysis. Overall, bariatric surgery is cost saving over the life course even without considering indirect costs. Health economists are hearing the call to present higher quality studies and include the costs of complications/reoperations; however, indirect costs and body contouring surgery are still not appropriately considered.

Gut Microbiota Imbalance Can Be Associated with Non-malabsorptive Small Bowel Shortening Regardless of Blind Loop

INTRODUCTION

Some traditional bariatric surgery procedures may lead to functional gut shortening, which may unsettle the fine-tuned gastrointestinal physiology and affect gut microbiota balance.

PURPOSE

Evaluate the gut microbiota behavior in rat models facing gut shortening due to intestinal bypass.

MATERIALS AND METHODS

Wistar rats (n = 17) were randomly distributed in three groups: (1) sham group (n = 5); (2) blind loop group (n = 6); and (3) resection group (n = 6). Intestinal samples and feces were analyzed to measure bacterial concentrations (small intestinal bacterial overgrowth-SIBO) 12 weeks after the experimental procedures. Bacterial translocation (BT) was investigated in the mesenteric lymph node (MLN), liver, spleen, and lung of the animals. In addition, inflammatory aspects were investigated in their liver and small bowel through histological analysis.

RESULTS

Regardless of blind loop, gut shortening groups recorded similar high level of bacterial concentrations in intestine compartments, greater than that of the sham group (p ≤ 0.05). BT was only observed in the MLN of gut shortening models, with higher percentage in the blind loop group (p ≤ 0.05). The gut and liver histopathological analysis showed similar low-grade chronic inflammation in both gut shortening groups, likely associated with SIBO/BT events.

CONCLUSION

Sustained SIBO/BT was associated with proximal gut shortening in half regardless of blind loop, whereas the GI tract's ability to restore gut microbiota balance after a surgical challenge on the small bowel appears to be linked to the functional remaining gut.

Polymeric Carriers for Controlled Drug Delivery in Obesity Treatment

The global rise in the prevalence of obesity and affiliated metabolic syndrome poses a significant threat to human health. Various approaches, including bariatric surgery and pharmacotherapy, have been used in the clinical setting for obesity treatment; however, these conventional options remain ineffective and carry risks of adverse effects. Therefore, treatments with higher efficacy and specificity are urgently required. Emerging drug delivery systems use polymeric materials and chemical strategies to improve therapeutic efficacy and specificity through stabilization and spatiotemporally controlled release of antiobesity agents. In this review, we provide insights into current treatments for obesity with a focus on recent developments of polymeric carriers for enhanced antiobesity drug delivery.

Gastric mucosal devitalization (GMD): translation to a novel endoscopic metabolic therapy

Background and study aims  The metabolic effects of bariatric surgery may partially result from removal of the gastric mucosa, an often underappreciated endocrine organ. Using argon plasma coagulation (APC), we may be able to selectively devitalize (ablate) the mucosa. The aim of this study was to identify the optimal tissue color that would correspond to selective gastric mucosal devitalization (GMD) using ex-vivo human stomach specimens. Patients and methods  Stomach specimens were obtained at sleeve gastrectomy. Prior to APC application, a submucosal fluid cushion was created. APC was then applied over a 2 × 2-cm area to the fundus and body, aiming for the three indicator colors (white, golden, brown). Pathological analysis was then performed independently and in a blinded fashion by two pathologists to determine the depth of mucosal and submucosal percent thermal injury and mucosal percent cell death. Results  Six patients were enrolled. There was a significant correlation between tissue color and mucosal percent thermal injury. The highest percent mucosal thermal injury was seen with brown (99.6 %, 95 % CI: 98.7, 100), followed by golden (92.5 %, 95 % CI: 85.5, 99.5), and then white (75.2 %, 95 % CI: 58.3, 92.1, P  < 0.01). Submucosal thermal injury was seen in 88.9 % of the slides. Greater than minimal submucosal injury (> 10 % depth) was found significantly more with brown tissue color (91.6 %) than golden (75 %) or white (33.3 %, P  < 0.05). However, 91.7 % of the entire sample set < 50 % injury. Conclusion  GMD is achievable using APC without thermal injury to muscularis propria. A golden color results in sufficient mucosal injury with only superficial injury to the submucosa.

An Approach to Obesity Management for Gastroenterologists and Hepatologists

PURPOSE OF REVIEW

Obesity is associated with multiple gastrointestinal and liver diseases such as gastroesophageal reflux disease, Barrett's esophagus, esophageal adenocarcinoma, cholelithiasis, colon polyps, and fatty liver disease. To effectively manage obesity, it is imperative to understand current and emerging therapies and procedures.

FINDINGS

Obesity is becoming increasingly prevalent and is associated with a growing monetary health care burden. Cardiac disease, cerebrovascular disease, and diabetes are among the leading causes of preventable and premature death of Americans related to obesity. In addition to behavioral modification (diet and exercise) and bariatric surgery, multiple pharmacotherapies and endoscopic procedures are newly approved and available for the management of obesity. This paper reviews the current literature on the treatments available for the management of obesity including behavior modification, pharmacotherapy, endoscopic weight loss procedures (endobariatrics), and bariatric surgery.

Increased Paracetamol Bioavailability after Sleeve Gastrectomy: A Crossover Pre- vs. Post-Operative Clinical Trial

Oral drug bioavailability may be significantly altered after laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure worldwide. Paracetamol (acetaminophen) is the post-bariatric analgesic/antipyretic drug of choice. In this work we studied and analyzed the LSG effects on systemic bioavailability and pharmacokinetics of paracetamol after oral administration of solid vs. liquid dosage form. A 4-armed, pharmacokinetic, crossover trial was performed in patients enrolled for LSG. Single paracetamol dose (500 mg), as caplet (n = 7) or syrup (n = 5), was administered before vs. 4–6 months post-LSG. Bioavailability was enhanced after LSG; in the caplet groups, average AUC_0–t increased from 9.1 to 18.6 µg·h/mL with AUC_0–t difference of 9.5 µg·h/mL (95% CI 4.6–14.5, p = 0.003). C_max increased from 1.8 (95% CI 1.2–2.5) to 4.2 µg/mL (3.6–4.8) after LSG (p = 0.032). In the syrup groups, AUC_0–t increased from 13.4 to 25.6 µg·h/mL, with AUC_0–t difference of 12.2 µg·h/mL (95% CI 0.9–23.5, p = 0.049). C_max changed from 5.4 (95% CI 2.5–8.4) to 7.8 µg/mL (6.1–9.6), and systemic bioavailability was complete (102%) after the surgery. Overall, decreased paracetamol exposure in obesity, with recovery to normal drug levels (caplet) or even higher (syrup) post-LSG, was revealed. In conclusion, attention to paracetamol effectiveness/safety in obesity, and after bariatric surgery, is prudent.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

A case report of an adjustable gastric band erosion and migration into the jejunum resulting in biliary obstruction

•

LAGB can rarely erode into the stomach and migrate into the small bowel.

•

Migration of the LAGB can result in bowel and biliary obstruction.

•

Band erosion should be managed by removal of the LAGB.

Introduction

Laparoscopic adjustable gastric band is a bariatric operation which has lost popularity due to its high rate of reoperation and complications such as band erosion. Erosion may be partial or complete with intragastric migration of the band. Once in the stomach lumen, the band has the potential to migrate into the small bowel.

Presentation of case

A 43-year-old male with history of morbid obesity and laparoscopic adjustable gastric band placement presented with abdominal pain secondary to biliary obstruction. Endoscopic retrograde cholangiopancreatography revealed eroded gastric band tubing into the lumen of the stomach and duodenum with resultant distortion of the ampulla. Upon surgical exploration, the band was found to have migrated into the jejunum and was removed through an enterotomy. The patient did well and was discharged home on postoperative day 8.

Discussion

Once completely eroded into the gastric lumen, a gastric band can migrate into the small bowel with the distance traveled being limited by the length of the connecting tube. The stretched tubing can result in distortion of the ampulla leading to biliary obstruction. Band erosion should be managed with band removal which can be completed using endoscopic, laparoscopic, or open approach.

Conclusion

Band migration should be suspected in patients with a history of gastric band placement presenting with bowel or biliary obstruction. Its management depends on the location of the band as well as the expertise of the surgical team.

Sex-Specific Glucose Homeostasis and Anthropometric Responses to Sleeve Gastrectomy in Obese Patients

Bariatric surgery rapidly and effectively treats obesity and its comorbidities like dysregulated glucose homeostasis. Despite the sex-balanced incidence of obesity in most human populations, women have sought this intervention more frequently than men. However, as the number of bariatric surgeries rapidly rises, it is increasingly urgent to understand how sex-specific differences may emerge in metabolic and anthropometric parameters. Hundred fifty-four obese patients (47% men and 53% women) from the Bialystok Bariatric Surgery Study underwent sleeve gastrectomy and were measured for 25 parameters at baseline (immediately prior to surgery) and at four follow-up visits over one year. We used generalized linear mixed models to detect sex-specific differences in the time series of responses parameters. Unlike most previous studies with older cross-sections of men than women, our cohort was age-matched, and men were less healthy at baseline. Of parameters that showed a significant cohort-wide (across-sex) response, 14 (56%) also showed sex-specific responses with men improving more than women. In particular, men remitted in diabetes symptoms more strongly, rapidly, and durably than women. Taken together, our results indicate that men may benefit more from sleeve gastrectomy and that this difference in improvement may be related to more progressed morbidity prior to surgery independent of age.

The Effects of Bariatric Surgery on Islet Function, Insulin Secretion, and Glucose Control

Although bariatric surgery was developed primarily to treat morbid obesity, evidence from the earliest clinical observations to the most recent clinical trials consistently demonstrates that these procedures have substantial effects on glucose metabolism. A large base of research indicates that bariatric surgeries such as Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and biliopancreatic diversion (BPD) improve diabetes in most patients, with effects frequently evident prior to substantial weight reduction. There is now unequivocal evidence from randomized controlled trials that the efficacy of surgery is superior to intensive life-style/medical management. Despite advances in the clinical understanding and application of bariatric surgery, there remains only limited knowledge of the mechanisms by which these procedures confer such large changes to metabolic physiology. The improvement of insulin sensitivity that occurs with weight loss (e.g., the result of diet, illness, physical training) also accompanies bariatric surgery. However, there is evidence to support specific effects of surgery on insulin clearance, hepatic glucose production, and islet function. Understanding the mechanisms by which surgery affects these parameters of glucose regulation has the potential to identify new targets for therapeutic discovery. Studies to distinguish among bariatric surgeries on key parameters of glucose metabolism are limited but would be of considerable value to assist clinicians in selecting specific procedures and investigators in delineating the resulting physiology. This review is based on literature related to factors governing glucose metabolism and insulin secretion after the commonly used RYGB and VSG, and the less frequently used BPD and adjustable gastric banding.

Systematic review on gastric electrical stimulation in obesity treatment

Introduction: Obesity is a very common public health problem worldwide. However, there is a lack of effective therapies. Only a small portion of patients with morbid obesity are accepting bariatric surgery as the last option due to the risks associated with invasive therapy. Areas covered: In this paper, we review an emerging weight loss treatment: gastric electrical stimulation (GES). The feasibility of GES as a potential therapy for obesity is introduced. Methodologies and parameters of GES are presented. Several GES methods for treating obesity and their effects on food intake and body weight are presented. Possible mechanisms involved in the anti-obesity effect of GES are discussed. Finally, our comments on the potential of GES for obesity and expectations for future development of the GES therapy are provided. The PubMed central database was searched from inception to May 2019. The literature search used the following terms: 'Gastric electrical stimulation' combined with 'obesity' and 'Implantable gastric stimulation' and 'pharmaceutical therapy' and 'bariatric surgery'. Expert opinion: There is a potential to use GES for treating obesity. However, more efforts are needed to develop appropriate stimulation devices and to design an adequate therapy for treating obesity in humans.

Prevalence of gastroesophageal reflux and risk factors for erosive esophagitis in obese patients considered for bariatric surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in obese individuals. Prospective studies investigating validated GERD questionnaires and clinical parameters at identifying erosive esophagitis (EE) in this population are limited.

OBJECTIVE

To prospectively evaluate the prevalence of GERD in obese patients considered for bariatric surgery and identify risk and predictive factors for EE.

METHODS

Eligible patients completed two validated questionnaires: GERDQ and Nocturnal Symptom Severity Impact (N-GSSIQ) before routine esophagogastroduodenoscopy.

RESULTS

242 consecutive patients were enrolled (130 females; mean age 37.8 ± 11.8 years; mean BMI 40.4 ± 5.3 kg/m2). The overall prevalence of gastroesophageal reflux (GERDQ ≥ 8, EE and/or PPI use) was 62.4%. EE was identified in 82 patients (33.9%) including 13/62 (21.0%) receiving PPIs at baseline. Multivariate logistic regression identified GERDQ ≥ 8 (OR = 6.3, 95%CI 3.0-13.1), hiatal hernia (OR = 4.2, 95%CI 1.6-10.7), abnormal Hill grade (OR = 2.7, 95%CI 1.4-5.4), and tobacco use (OR = 2.5, 95%CI 1.2-4.9) as independent risk factors for EE. A pre-endoscopic composite assessment including GERDQ ≥ 8 and presence of severe nocturnal reflux symptoms had 90% specificity and 20.7% sensitivity in identifying EE (NPV 68.9% and PPV 51.5%).

CONCLUSION

GERD is highly prevalent in obese patients. Anthropometric data and GERD questionnaires have limited accuracy at predicting erosive disease. Pre-operative endoscopic assessment in this population appears warranted.

Utilizing the lateral excess for autologous augmentation in massive weight loss patients

The number of patients in need of a mastopexy with autologous augmentation after massive weight loss (MWL) increases along with the increasing number of bariatric surgeries. The primary aim of this paper was to visualize how we utilize the lateral excess of the breast for auto augmentation. The secondary aim was to assess the outcome using the LOPOSAM technique in a larger study population. This retrospective study included 72 MWL patients aged 40±9 years undergoing a bilateral LOPOSAM procedure, between March 2015 and April 2018. All patients had undergone a weight loss of more than 15 BMI units, had a BMI of less than 30 kg/m2 at the time of surgery and functional problems due to excess or lax skin. Patient demographics, comorbidities, cause of MWL, operative time and complications were recorded. The mean weight loss was 58±18 kg or 21±6 BMI units. The mean operative time was 97±39 minutes. The surgical goal was achieved in all patients. Three patients (4%) experienced hematomas requiring surgical intervention. The utilization of the lateral excess of the breast for auto augmentation in MWL patients is visualized. The long term results using the LOPOSAM mastopexy technique shows that the technique is quick, safe and with a low rate of complications.

Non-Bariatric Roux-en-Y Gastric Bypass

Background: Roux-en-Y gastric bypass (RYGB) is frequently performed for weight loss purposes in the morbidly obese population. The popularity and acceptance of this procedure have increased the knowledge of the physiological (anatomical and functional) changes that this technique produces in the organism. RYGB improves gastric emptying and gastroesophageal reflux symptoms. Materials and Methods: We analyzed 6 patients in whom an RYGB was performed for non-bariatric purposes. Symptom questionnaire was used to evaluate response. Results: None of the patients qualified for bariatric surgery, as all had a body mass index (BMI) <35 kg/m². Five patients were operated on for severe gastroesophageal reflux disease symptoms, and one for gastroparesis. All patients had good to excellent results, with marginal modification of their BMI. Conclusion: Non-bariatric RYGB can be considered in patients with functional diseases of the upper gastrointestinal tract, regardless of their BMI.

Nephrolithiasis after bariatric surgery: A comparison of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy

INTRODUCTION

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is known to increase risk for calcium oxalate nephrolithiasis due to hyperoxaluria; however, nephrolithiasis rates after laparoscopic sleeve gastrectomy (LSG) are not well described. Our objective was to determine the rate of nephrolithiasis after LRYGB versus LSG.

METHODS

The electronic medical records of patients who underwent LRYGB or LSG between 2001 and 2017 were retrospectively reviewed.

RESULTS

1,802 patients were included. Postoperative nephrolithiasis was observed in 133 (7.4%) patients, overall, and 8.12% of LRYGB (122/1503) vs. 3.68% of LSG (11/299) patients (P < 0.001). Mean time to stone formation was 2.97 ± 2.96 years. Patients with a history of UTI (OR = 2.12, 95%CI 1.41-3.18; P < 0.001) or nephrolithiasis (OR = 8.81, 95%CI 4.93-15.72; P < 0.001) were more likely to have postoperative nephrolithiasis.

CONCLUSION

The overall incidence of symptomatic nephrolithiasis after bariatric surgery was 7.4%. Patients who underwent LRYGB had a higher incidence of nephrolithiasis versus LSG. Patients with a history of stones had the highest risk of postoperative nephrolithiasis.

Technical Details and Result of a Minimally Invasive Management of Gastric Band Erosions: a Series of 47 Patients

INTRODUCTION

Laparoscopic adjustable gastric banding (LAGB) is proven to be a safe and effective treatment option for obesity in the long term. However, in recent decades, LAGB prevalence progressively decreased worldwide principally due to the incidence and the management of the complications. Understanding the optimal management of the complications becomes therefore of primary importance. The aim of this study is to describe a personal technical, laparoscopic solution of band erosion and to analyze outcomes in 47 patients.

METHODS

From October 1995 to January 2019, 3697 LAGB were performed at our institution. Since November 2011, an original laparoscopic gastric banding removal technique was introduced. All the bands placed in these patients were Lap-Band AP System (Allergan, Irvin, CA). The data of the patients who underwent gastric band removal because of band erosion were retrieved from a prospectively collected institutional database, and used for the present retrospective evaluation.

RESULT

Ninety-four patients (2.5% of the entire casuistic) with eroded band were diagnosed and treated at our institution. Forty-seven patients were treated with the laparoscopic gastric banding removal technique introduced in November 2011. All the operations have been performed laparoscopically with no conversion or intraoperative complications. There were neither major complications nor peri-operative (30 days) mortality.

CONCLUSION

Proper preoperative management and a standardized minimally invasive technique could help to cope with erosion, the most frightening complication of LAGB. Understanding the optimal management of complications and safe reoperation techniques can contribute to a rational use of the LAGB, reversing the current declining tendency.

Gastroesophageal reflux disease, obesity and laparoscopic sleeve gastrectomy: The burning questions

Obesity is a global health epidemic with considerable economic burden. Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk. Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease (GERD) has been a topic of debate. GERD, including erosive esophagitis, is highly prevalent in the obese population. The role of pre-operative endoscopy in bariatric surgery has been controversial. Two schools of thought exist on the matter, one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology. This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy (LSG) with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure. In this paper, we try to address 3 burning questions regarding the inter-relationship of obesity, GERD, and LSG: (1) What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery? (2) Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery? And (3) What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?

Endoscopic Bariatric Therapy: A Guide to the Intragastric Balloon

Intragastric balloons (IGBs) are the most widely available endoscopic bariatric therapy for class I and II obesity in the United States. Although simple in application and reversible by nature, these devices may help patients initiate the important first steps in weight loss maintenance, provided that parallel efforts are in motion to prevent weight recidivism. Too often, therapeutic nihilism stems from unrealistic expectations of a given therapy. In the case of IGBs, this sentiment may occur when these interventions are applied in a vacuum and not within the purview of a multidisciplinary program that actively involves dieticians, endocrinologists, gastroenterologists, and surgeons. There is a clear and present need to apply different tactics in the remissive strategy to control the obesity pandemic, more so in a struggling landscape of an ever-widening gap in bridging interventions. With such demand, the IGB is an available tool that could be helpful when correctly implemented. In this exposition, we summarize the current state of IGBs available worldwide, discuss their mechanism of action, relay evidence for their short- and long-term efficacy, address safety profile concerns, and suggest procedural considerations in the real-world quotidian application.

Incremental Cost-Effectiveness of Aspiration Therapy vs Bariatric Surgery and No Treatment for Morbid Obesity

INTRODUCTION

Despite its recent approval by the US Food and Drug Administration and Health Canada, aspiration therapy-one of the latest weight loss treatments-remains controversial. Critics have expressed concerns that the therapy could lead to bulimia and other binge eating disorders. Meanwhile, proponents argue that the therapy is less invasive, reversible, and cheaper than bariatric surgery. Cost-effectiveness of this therapy, however, is not yet established.

METHODS

We developed a Markov model to estimate the incremental cost-effectiveness of aspiration therapy relative to 2 most common bariatric surgery procedures (gastric bypass and sleeve gastrectomy) and no treatment over a lifetime horizon. Costs were estimated from the health system's perspective using US data. Effectiveness was measured in terms of quality-adjusted life-years (QALYs).

RESULTS

Despite being a cheaper procedure than bariatric surgery, aspiration therapy costs more than bariatric surgery in the long term because of its high maintenance costs (i.e., periodic replacement of device parts). It also yields lower QALYs than bariatric surgery because of its smaller weight loss effects. Thus, the therapy is dominated by bariatric surgery. In particular, compared with gastric bypass, it costs US$5,318 more and yields 1.31 fewer QALYs. However, aspiration therapy is cost-effective relative to no treatment with an incremental cost-effectiveness ratio of US$17,532 per QALY gained.

DISCUSSION

Given its high lifetime costs and its modest weight loss effects, aspiration therapy is not cost-effective relative to bariatric surgery. However, it is a cost-effective treatment option for patients who lack access to bariatric surgery.

Preoperative Thyroid Autoimmune Status and Changes in Thyroid Function and Body Weight After Bariatric Surgery

BACKGROUND

Bariatric surgery has emerged as the most effective therapy for morbid obesity. There is increasing evidence that bariatric surgery could alleviate systemic inflammation and influence thyroid function. The current study aimed to investigate the associations of preoperative thyroid autoimmune status with the changes in body weight and thyroid function after bariatric surgery.

METHODS

We recruited 101 patients with morbid obesity (44 men and 57 women) who received bariatric surgery at Zhongshan Hospital, Fudan University. Those who had used thyroid hormone replacement or antithyroid drugs were excluded. General linear models were used to compare the changes in body weight and thyroid function in participants with different thyroid autoimmune statuses.

RESULTS

After bariatric surgery, serum-free triiodothyronine (FT3) (4.94 ± 0.73 vs 4.33 ± 0.59 pmol/L, P < 0.001) and thyroid-stimulating hormone (TSH) (3.13 ± 1.59 vs 2.26 ± 1.26 μIU/mL, P < 0.001) were significantly reduced, accompanied by reductions in BMI (42.1 ± 7.6 vs 31.4 ± 6.5 kg/m2, P < 0.001), and estimated basal metabolic rate (2002 ± 398 vs 1700 ± 336 kcal/day, P = 0.001) and an improvement in lipid profiles. Serum thyroperoxidase antibody (TPOAb) and thyroglobulin antibody (TgAb) levels also decreased significantly from 79.3 and 177.1 IU/mL to 57.8 and 66.0 IU/mL in participants with positive thyroid antibodies (P < 0.05). Further analysis showed that the positive preoperative thyroid autoimmune status was associated with less reduction in serum TSH (0.05 ± 1.59 vs - 1.00 ± 1.43 μIU/mL, P = 0.021) and BMI (- 8.3 ± 3.6 vs - 11.0 ± 4.5 kg, P = 0.049) after bariatric surgery.

CONCLUSION

Our study highlights a group of patients with morbid obesity, who have positive preoperative thyroid autoimmunity and less reduction in serum TSH levels and body weight after bariatric surgery.

Bariatric surgery for prospective living kidney donors with obesity?

The obesity epidemic has gripped the transplant community. With nearly 40% of adults in the United States being obese (BMI ≥30 kg/m² ) and 20% being morbidly obese (BMI ≥35 kg/m² ), the implications for both donors and recipients of solid organs continue to grow.¹ Nowhere is this more impactful than the candidacy of living kidney donors (LKDs). As increasing numbers of obese adults present for LKD consideration and evidence of inferior outcomes among obese LKDs grows, transplant surgeons will become progressively challenged by how to manage these patients in the clinic. Therefore, we offer this Personal Viewpoint to the transplant surgery community in order to review the current impact of obesity on living kidney donation, highlight what weight-loss interventions have already been attempted, and discuss the role that referral for weight-loss interventions including bariatric surgery might have going forward.

The effect of bougie size and distance from the pylorus on dehydration after laparoscopic sleeve gastrectomy: an analysis of the ACS-MBSAQIP database

BACKGROUND

Dehydration is the most common cause of readmission after laparoscopic sleeve gastrectomy (SG). Bougie size and distance from the pylorus, both of which have been associated with rates of dehydration postoperatively, varies by surgeon and across institutions.

OBJECTIVES

To determine if there is an association between bougie size or distance from the pylorus on the rate of dehydration after laparoscopic SG.

SETTING

American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database.

METHODS

All patients undergoing first-time, elective laparoscopic SG from 2015-2016 were identified. The association of bougie size and distance from the pylorus on the rate of dehydration within the first 30 days postoperatively was investigated.

RESULTS

The inclusion criteria were met by 170,751 patients. The most commonly used bougie size was 36 Fr and the most common distance from the pylorus at which the gastric sleeve was started was 5 cm. Patients were divided into 4 groups based on bougie size and distance from the pylorus (Group 1: bougie size <36 Fr, pylorus distance <4 cm; Group 2: bougie size ≥36 Fr, pylorus distance <4 cm; Group 3: bougie size ≥36 Fr, pylorus distance ≥4 cm; and Group 4: bougie size <36 Fr, pylorus distance ≥4 cm). Patients in Group 4 were significantly less likely than any other group to experience dehydration-related complications.

CONCLUSION

Both distance from the pylorus and bougie size are significantly associated with dehydration-related complications after SG. Consideration should be made for standardizing these technical aspects of SG to help reduce the rate of postoperative dehydration and hospital readmission.

A case report of retrograde intussusception 3 years post Roux-en-Y gastric bypass

Retrograde jejuno-jejunal intussusception is a rare complication of bariatric surgeries. It causes acute sudden symptoms that require immediate surgical intervention. We report a case of a 46-year-old female who underwent Roux-en-Y gastric bypass (REYGP) 3 years prior. The patient presented to the emergency department with acute sudden abdominal pain, nausea and vomiting. Laparoscopically, intussuscepting small bowel segment was found gangrenous, and it was resected and end-to-end anastomoses were fashioned. The postoperative course was uneventful, and the patient remained asymptomatic for the 12 months of follow-up. Patients with retrograde intussusception experience an intolerable severe pain that necessitates surgical intervention. The etiology of intussusception as a complication after REYGP is unclear, yet theoretically some possible etiologies exist. The initial diagnosis of retrograde intussusception is made based on abdominal computed tomography. Early intervention significantly reduces morbidity and mortality.